Provider Demographics
NPI:1750767281
Name:KIESER, SAMANTHA (ATC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KIESER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14425 40TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3303
Mailing Address - Country:US
Mailing Address - Phone:763-257-2604
Mailing Address - Fax:
Practice Address - Street 1:14425 40TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3303
Practice Address - Country:US
Practice Address - Phone:763-257-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer